AJN Patient-Oriented, Translational Research: Research Article
American Journal
of Nephrology Am J Nephrol
DOI: 10.1159/000532109
Effects of Different Exercises on Physical
Function, Dialysis Adequacy, and
Health-Related Quality of Life in Maintenance
Hemodialysis Patients: A Systematic Review and
Network Meta-Analysis
Huagang Hu a, b Chanchan Wu a Jojo Yan Yan Kwok a Mu-Hsing Ho a
Pui Hing Chau a Kris Yuet Wan Lok a Edmond Pui Hang Choi a
aSchool of Nursing, LKS Faculty of Medicine, The University of Hong Kong, Hong Kong, China; bSchool of
Nursing, Suzhou Medical College of Soochow University, Suzhou, China
Keywords
Exercise · Maintenance hemodialysis · Network meta-analysis
Abstract
Background: Clinical guidelines recommend exercise
training for patients undergoing maintenance hemodialysis
(MHD). However, the effectiveness of different types of
exercise remains uncertain. Objectives: The aims of the
study were to compare and rank the effect of different types
of exercise on walking capacity, cardiorespiratory fitness,
dialysis adequacy, and health-related quality of life (HRQOL)
in patients undergoing MHD. Methods: Eight databases
(four English and four Chinese) were searched from in-
ception to January 1, 2022. Randomized controlled trials
evaluating the efficacy of different exercises for patients
undergoing MHD were included. Two independent re-
viewers screened the literature, extracted data, assessed the
risk of bias, and evaluated the certainty of evidence. A
frequentist random-effect network meta-analysis was con-
ducted. Results: Ninety trials with 4,084 participants com-
paring 15 types of exercise were included, reporting on the
six-minute walking test (45 trials), peak oxygen uptake (22
karger@karger.com © 2023 The Author(s).
www.karger.com/ajn Published by S. Karger AG, Basel
This article is licensed under the Creative Commons Attribution-
NonCommercial 4.0 International License (CC BY-NC) (http://www.
karger.com/Services/OpenAccessLicense). Usage and distribution for
commercial purposes requires written permission.
Received: May 8, 2023
Accepted: July 13, 2023
Published online: August 3, 2023
Downloaded from http://karger.com/ajn/article-pdf/doi/10.1159/000532109/3998785/000532109.pdf by guest on 20 November 2023
trials), dialysis adequacy (30 trials), and HRQOL (23 trials).
Network meta-analysis showed that the most effective in-
tervention for walking capacity was intradialytic aerobic
exercise combined with blood flow restriction with a
mean difference and 95% confidence interval of 97.35
(11.89–182.81), for peak oxygen uptake it was non-
intradialytic combined aerobic and resistance exercise
with a value of 4.35 (2.25–6.44), for dialysis adequacy it was
intradialytic combined aerobic and resistance exercise with
a value of 0.17 (0.06–0.28), for the physical component
summary of HRQOL it was intradialytic aerobic exercise with
a value of 4.93 (2.31–7.54), and for the mental component
summary of HRQOL it was non-intradialytic combined
aerobic and resistance exercise with a value of 6.36
(0.45–12.27). Ultimately, intradialytic combined aerobic and
resistance exercise could improve all the above outcomes
compared to usual care. Conclusions: This study concluded
that intradialytic combined aerobic and resistance exercise
is optimal for MHD patients due to its significant positive
effects on multiple outcomes. Walking capacity can be
Huagang Hu and Chanchan Wu contributed equally to this work and
share first authorship.
Correspondence to:
Edmond Pui Hang Choi, h0714919 @ connect.hku.hk
further enhanced by combining blood flow restriction with
exercise. For improving dialysis adequacy, intradialytic ex-
ercise proves to be more effective than non-intradialytic
exercise. Further well-designed clinical trials are needed to
investigate the effects of exercise with varying durations,
intensities, and frequencies. © 2023 The Author(s).
Published by S. Karger AG, Basel
Introduction
The number of patients undergoing maintenance he-
modialysis (MHD) is continuously increasing worldwide
[1]. Symptom clusters of renal disease, long dialysis duration,
and multi-comorbidity contribute to inferior physical fitness
and poor health-related quality of life (HRQOL) in patients
undergoing MHD [2]. Cardiorespiratory fitness and walking
capacity are important physical fitness indicators of great
concern to people with MHD, but their performance is
usually worse compared to their age-matched healthy
counterparts [3, 4]. Impaired physical function and HRQOL
are associated with adverse outcomes, such as higher
mortality and hospitalization rates [5].
Exercise training is an ideal alternative intervention for
MHD patients. According to the Renal Association Clinical
Practice Guideline on Hemodialysis, dialysis patients need
to do exercises, especially intradialytic exercises [6, 7].
Traditional exercise types include aerobic, resistance, and
balance exercise [7]. Furthermore, recent years have seen
the introduction of new elements in exercise protocols, such
as virtual reality (VR) and blood flow restriction (BFR),
which have been reported to be more effective than a single
type of exercise for MHD patients [7]. Several published
meta-analyses have shown that some exercise types could
improve walking capacity, cardiorespiratory fitness, dialysis
adequacy, and HRQOL for MHD patients [8–18]. However,
the most effective exercise type for this population remains
unknown [12, 19].
Pairwise meta-analysis could pool the impact of the same
type of exercise compared to the usual care (UC), but it
could not conduct an indirect comparison between different
types of exercises [20]. In contrast, network meta-analysis
(NMA) can fill these gaps by synthesizing direct and in-
direct comparisons to evaluate various intervention forms
and determine which is the most effective [20]. To date,
three NMA have been conducted to compare the effects of
different exercise types or intensities on cardiorespiratory
fitness, walking capacity, dialysis adequacy, and blood
pressure in MHD patients [12, 21, 22]. Although these
published NMA compared the effect of UC, aerobic exercise
(AE), resistance exercise (RE), combined aerobic and re-
2 Am J Nephrol
DOI: 10.1159/000532109
sistance exercise (CE), and other types of exercise, they
grouped intradialytic and non-intradialytic exercises to-
gether, leaving it unclear which and when exercise is more
effective for this population [12, 21, 22]. Different exercise
types have varying benefits for various outcomes. Exercises
conducted during and out of hemodialysis may have unique
benefits and limitations [23]. Therefore, it is important to
evaluate the effect of different exercise types with a more
detailed classification, as this can provide direct evidence for
selecting exercise in clinical practice. The current NMA
aimed to synthesize the direct and indirect evidence to
compare the effectiveness of different types of exercise for
walking capacity, cardiorespiratory fitness, dialysis ade-
Downloaded from http://karger.com/ajn/article-pdf/doi/10.1159/000532109/3998785/000532109.pdf by guest on 20 November 2023
quacy, and HRQOL in MHD patients.
Methods
Study Design
This systematic review and NMA was conducted following the
Cochrane Handbook for Systematic Reviews of Interventions [24]
and reported according to the Preferred Reporting Items for Sys-
tematic Reviews and Meta-Analyses for Network Meta-Analysis
(PRISMA-NMA) [20]. The protocol of this study was registered
on the PROSPERO platform (reference: CRD42021286114).
Search Strategy and Selection Criteria
Four English databases (PubMed, EMBASE, Cochrane Library,
and Web of Science) and four Chinese databases (WAN FANG
Data; China National Knowledge Infrastructure; VIP Chinese
Science and Technology Journal Database; Chinese BioMedical
Literature Database) were searched from their inception to January
1, 2022. Two researchers (H.H. and W.C.) developed the search
strategy and finalized it after consulting a senior researcher (EC).
The search strategy for PubMed is shown in online supplementary
Table 1 (for all online suppl. material, see https://doi.org/10.1159/
000532109). The references of published systematic reviews were
also screened and searched for additional studies [4, 10–13, 17, 18,
25–28]. After deduplication, two reviewers (H.H. and W.C.) in-
dependently screened titles, abstracts, and full-text of potentially
eligible studies based on the inclusion and exclusion criteria. Any
disagreements arising during the article selection process were
resolved after discussions among H.H., W.C., and E.C.
We conducted a comprehensive analysis of randomized controlled
trials published in English and Chinese to assess the effects of exercise
on patients undergoing MHD. The study included adult participants
(≥18 years old) who had been receiving hemodialysis treatment for at
least 3 months. All types of non-intradialytic and intradialytic exercise
interventions were considered, with comparison groups comprising
UC and sham exercise. Exclusion criteria for this study were as
follows: participants receiving renal replacement therapies other than
hemodialysis (e.g., peritoneal dialysis or renal transplant); interven-
tions consisting solely of exercise instructions and education, rather
than specific exercise programs; single-session exercise interventions;
articles with abstracts only; studies with no relevant outcomes; and
studies lacking essential data after three attempts to contact authors
via email.
Hu/Wu/Kwok/Ho/Chau/Lok/Choi
 According to the literature review [3], the outcomes selected were
considered clinically important and of great concern to patients. The
primary outcome of this study was walking capacity (assessed by the
six-minute walking test, 6MWT). The secondary outcomes included
cardiorespiratory fitness (assessed by peak oxygen uptake, VO2peak),
dialysis adequacy (assessed by Kt/V, where K means dialyzer clear-
ance of urea, t means dialysis time, and V means the volume of
distribution of urea), and HRQOL. The HRQOL was assessed by the
Medical Outcomes Study Short-Form 36 (SF-36), 12-Item Short
Form Survey (SF-12), or Kidney Disease and Quality of Life™ Short
Form which was included in SF-36 or SF-12. All of the above HRQOL
measurements have a standard score from 0 to 100, with higher scores
indicating better HRQOL [29].
Data Extraction and Risk-Of-Bias Assessment
Two independent researchers (H.H. and W.C.) carried out data
extraction and risk of bias assessment for the included studies
independently. Any disagreements were resolved through dis-
cussions with the senior researcher (E.C.). We developed and
tested a data extraction form to gather basic article information
(title, setting, journal, publication year, language, etc.) and study
details (number of participants, sociodemographic, duration of
MHD, time and duration of implementation, types of intervention
and control, attrition, and outcomes). All relevant results from the
included studies were collected and analyzed.
Two independent researchers conducted a risk of bias assessment
at the outcome level, utilizing the Risk of Bias tool 2.0 (RoB 2.0) from
the Cochrane Collaboration [30]. The quality of evidence was eval-
uated using the Grading of Recommendations Assessment, Devel-
opment, and Evaluation (GRADE) for pairwise meta-analysis, as well
as the ranking of NMA [31]. The confidence in the NMA effect
estimates for all outcomes was assessed using the Confidence In
Network Meta-Analysis (CINeMA) approach [32].
Statistical Analyses
The mean difference (MD) and 95% confidence interval of
changes from baseline to the end of intervention were used as the
effect estimate [24]. If the authors did not report the value of these
changes, we calculated them using the data from the baseline and
end-of-study, as recommended by the Cochrane Handbook [24].
First, we conducted a pairwise meta-analysis using a random-effect
analysis model with RevMan (Version 5.3, Cochrane) to make
direct comparisons between interventions and comparators [33].
The χ2 test and I2 statistics were used to test the data heterogeneity
[34]. Second, a frequentist NMA was conducted via the mvmeta
command in Stata (Version 14.1, Stata Corp., College Station, TX,
USA), following a five-step process [35].
• Step 1: generating network geometry to explore the relation-
ships among interventions.
• Step 2: using the Wald χ2 test to assess global inconsistency and
side-splitting to assess local inconsistency. If there was no
evidence of inconsistency, the consistency model was applied to
conduct the NMA with the random-effect model.
• Step 3: creating a league table to display the effect size by
interventions.
• Step 4: using the surface under the cumulative ranking (SU-
CRA) and the probability of being best to identify the supe-
riority of interventions. When there are inconsistencies between
SUCRA and the probability of being best, SUCRA is considered
the more reliable recommended estimate [35, 36].
Exercise in Hemodialysis Patients
• Step 5: using Egger test and visually inspected asymmetry of the
NMA funnel plots to assess the publication bias [35].
The statistical significance level is 0.05.
Results
Study Characteristics
We identified 6,832 records of potentially relevant
publications, of which 253 articles were screened for full text
(as shown in Fig. 1). Finally, 90 randomized controlled trials
involving 4,084 participants were included in this study (as
shown in online suppl. Table S2), of which 85 studies were
published in English and five were published in Chinese.
Downloaded from http://karger.com/ajn/article-pdf/doi/10.1159/000532109/3998785/000532109.pdf by guest on 20 November 2023
The sample size ranged from 13 to 234 participants. The
frequency of exercise ranged from 2 to 7 days per week, with
the majority being 3 days (70/90 studies).
The exercise types primarily consisted of AE (33 arms
during dialysis and 9 arms outside of dialysis), RE (19
arms during dialysis and 2 arms outside of dialysis), and
CE (22 arms during dialysis and 10 arms outside of
dialysis). Most AE protocols involved cycling during
dialysis and walking or cycling outside of dialysis. REs
mainly focused on leg or nonvascular access side limb
exercises with ankle weights, dumbbells, elastic resistance
bands, or weight training machines during or outside of
dialysis. Other elements reported in exercise interven-
tions for MHD patients included VR, BFR, functional
training, balance exercise, inspiratory muscle training
(IMT), and neuromuscular electrical stimulation, among
others. The comparators consisted of UC (69 arms) and
sham exercise (12 arms). Details of the interventions, the
control group, and their descriptions are presented in
Table 1. The network plots for outcomes are shown in
Figure 2. The size of the nodes represents the number of
participants involved in each type of intervention, while
the thickness of lines between interventions indicates the
number of studies comparing those interventions.
Synthesis of Results
Forty-five studies, featuring 98 arms and 15 types of
interventions, reported on the 6MWT. The pairwise meta-
analysis results revealed that, compared to UC, four types of
intradialytic exercise (i.e., aerobic, resistance, combined
aerobic and resistance, and IMT) significantly improved the
6MWT with very low to low-quality evidence (as shown in
online suppl. Table S3). The NMA results indicated that nine
exercise types could improve walking distance in MHD
patients compared with UC. The SUCRA ranking indicated
that intradialytic AE (IAE) combined with BFR, intradialytic
IMT, and intradialytic RE (IRE) plus virtual reality were the
Am J Nephrol 3
DOI: 10.1159/000532109

Fig. 1. PRISMA flow diagram of search process for studies examining the efficacy of exercise in MHD patients.
top three exercise modalities for improving the 6MWT.
These were followed by non-intradialytic CE (NCE) plus
balance training, intradialytic CE (ICE), and IAE. Their effect
sizes (MD, 95% confidence interval) paired with UC were
97.35 (11.89–182.81), 77.27 (38.14–116.40), 77.98
(5.85–150.12), 66.12 (7.88–124.35), 53.71 (30.08–77.35), and
51.14 (28.21–74.08), respectively (as shown in Table 2; online
suppl. Table S4; online suppl. Fig. S1). The confidence of the
evidence for interventions was moderate for the 6MWT (as
shown in Table 3; online suppl. Table S5).
For the VO2peak outcome, we analyzed 22 studies with
47 arms and seven types of interventions. The pairwise
meta-analysis results showed that, compared to UC, four
types of exercise (i.e., AE and combined aerobic and
resistance, both conducted during and outside of dialysis)
significantly improved VO2peak with very low quality of
the evidence (as shown in online suppl. Table S3). The
NMA results indicated that these four exercise types
could improve VO2peak in MHD patients compared with
UC. The SUCRA ranking indicated that, NCE was the
most effective form of exercise for improving VO2peak.
This was followed by non-IAE and ICE. The effect sizes
paired with UC were 4.35 (2.25–6.44), 4.31 (1.62–7.00),
4 Am J Nephrol
DOI: 10.1159/000532109
Downloaded from http://karger.com/ajn/article-pdf/doi/10.1159/000532109/3998785/000532109.pdf by guest on 20 November 2023
and 3.86 (2.24–5.49), respectively (as shown in Table 2,
online suppl. Table S6; online suppl. Fig. S2). The con-
fidence of the evidence for interventions was low for
VO2peak (as shown in Table 3; online suppl. Table S7).
A total of 30 studies with 66 arms and 11 types of in-
terventions were included in the analyses of Kt/V. The
pairwise meta-analysis results showed that, compared to
UC, IAE and intradialytic combined aerobic and resistance
could significantly improve the Kt/V with low quality of the
evidence (as shown in online suppl. Table S3). The NMA
results were similar to the pairwise meta-analysis. The
SUCRA ranking indicated that ICE was the most effective
form of exercise for improving Kt/V, followed by IAE. The
effect sizes paired with UC were 0.17 (0.06–0.28) and 0.13
(0.07–0.19), respectively (as shown in Table 2; online suppl.
Table S8; online suppl. Fig. S3). The confidence of the
evidence for interventions was low for Kt/V (as shown in
Table 3; online suppl. Table S9).
For the physical component summary (PCS) of
HRQOL, we analyzed 23 studies with 53 arms and 10
types of interventions. The pairwise meta-analysis results
showed that, compared to UC, IAE and ICE could sig-
nificantly improve the PCS with very low and moderate
Hu/Wu/Kwok/Ho/Chau/Lok/Choi
Table 1. Types of interventions and controls of included studies

Types Description Number of Number of

arms participants

Intervention
IAE IAE typically involves patients pedaling on a cycle ergometer during hemodialysis 33 555
sessions, which occur 2–3 times per week at low to moderate intensity. The average
exercise duration is approximately 30 min per session
IRE IRE mainly consists of leg or nonvascular access side limb exercises performed during 19 408
hemodialysis sessions. These exercises typically involve the use of ankle weights,
dumbbells, elastic resistance bands, or weight training machines, and are conducted
at low to moderate intensity, 2–3 times per week
ICE ICE involves performing both AE and RE protocols, as described above, during 22 494
hemodialysis sessions
NAE NAE primarily consists of 15–45-min walking or cycling sessions performed at home, 9 188

Downloaded from http://karger.com/ajn/article-pdf/doi/10.1159/000532109/3998785/000532109.pdf by guest on 20 November 2023

outside of hemodialysis sessions, occurring 3–4 times per week
NRE NRE involves resistance training using light weights, dumbbells, resistance bands, or 2 72
weight machines with low to moderate loads, performed outside of hemodialysis
sessions, 3 times per week
NCE NCE involves performing both NAE and NRE protocols, typically 3–7 times per week, 10 234
outside of hemodialysis sessions
IIMT IIMT involves using a breathing training device to strengthen inspiratory muscles 3 63
during hemodialysis sessions, typically performed 3 times per week
NIMT NIMT involves practicing inspiratory muscle exercises with or without a breathing 3 70
training device outside of hemodialysis sessions, typically performed 2–7 times per
week
CIMT Combined inspiratory muscle training involves using a breathing training device 1 14
with a load of 50–70% maximum inspiration pressure to strengthen inspiratory
muscles both during hemodialysis (3 times weekly) and on non-hemodialysis days
(3 times weekly)
INES INES involves using electrical stimulation on the bilateral femoral quadriceps 5 72
muscles during hemodialysis for a duration of 20–40 min
IAE IAE combined with non-intradialytic resistance training involves performing 3 85
+ NRE exercises using dumbbells or fitness apparatus outside of hemodialysis sessions. The
program includes both AE and resistance training
IRE IRE combined with VR involves following the same RE protocol during hemodialysis 2 27
+ VR as described above. Additionally, up to 30 min of non-immersive gaming is used as a
form of VR to improve the dialysis experience
IAE IAE combined with BFR involves performing cycling exercises during hemodialysis 1 18
+ BFR with inflatable bands around both proximal thighs to reduce arterial blood flow by
50% in the lower limbs
IAE IAE combined with FT involves performing full range of motion exercises with 1 16
+ FT additional weights guided by a kinesiologist, three times a week during
hemodialysis. The program includes both AE and FT
NCE NCE is added to BE in a program that spans 24 weeks. The program includes a 1 26
+ BE combination of aerobic and RE in the first and third sessions of each week, while the
second and fourth sessions focus on BEs. The BE program includes stance exercise,
transition exercise, gait exercise, and functional strength exercises that last 30 min
per session
Control
UC “UC” refers to the standard care that is typically given to patients during 69 1,516
hemodialysis sessions
SE An SE intervention might involve simple stretching or low-load exercises that do not 12 226
provide a significant cardiovascular or resistance training stimulus

AE, aerobic exercise; RE, resistance exercise; IMT, inspiratory muscle training, BE, balance exercise; FT, functional training; BFR, blood
flow restriction; VR, virtual reality; UC, usual care; SE, sham exercise; INES, intradialytic neuromuscular electrical stimulation; IIMT, in-
tradialytic inspiratory muscle training; NIMT, non-intradialytic inspiratory muscle training; CIMT, combined inspiratory muscle training
during hemodialysis and non-hemodialysis days; IAE, intradialytic aerobic exercise; IRE, intradialytic resistance exercise; ICE, intradialytic
combined aerobic and resistance exercise; NAE, non-intradialytic aerobic exercise; NRE, non-intradialytic resistance exercise; NCE, non-
intradialytic combined aerobic and resistance exercise.

Exercise in Hemodialysis Patients Am J Nephrol 5

DOI: 10.1159/000532109
quality of the evidence (as shown in online suppl. Table
S3). The NMA results were similar to the pairwise meta-
analysis. The SUCRA ranking indicated that, IAE was the
most effective form of exercise for improving PCS, fol-
lowed by ICE. The effect sizes paired with UC were 4.93
(2.31–7.54) and 3.90 (1.79–6.02), respectively (as shown
in Table 2, online suppl. Table S10; online suppl. Fig. S4).
The confidence of the evidence for interventions was
moderate for PCS (as shown in Table 3; online suppl.
Table S11).
For the mental component summary (MCS) of
HRQOL, 21 studies with 49 arms and 10 types of in-
terventions were analyzed. The results from pairwise
meta-analysis showed that, compared to UC, IRE and
intradialytic neuromuscular electrical stimulation could
significantly improve the MCS with very low and low-
quality evidence, respectively (as shown in online suppl.
Table S3). However, the results from NMA showed that
IRE, ICE, and NCE could improve MCS for MHD pa-
tients compared with UC. In addition, the SUCRA
ranking indicated that NCE was the most effective form
of exercise for improving MCS, followed by non-IAE. The
effect sizes paired with UC were 6.36 (0.45–12.27) and
8.19 (−5.98-22.37), respectively (as shown in Table 2;
online suppl. Table S12, and online suppl. Fig. S5). The
inconsistent results among pairwise meta-analysis, NMA,
and SUCRA would downgrade the qualities of evidence.
The confidence of the evidence for interventions was low
for MCS (as shown in Table 3; online suppl. Table S13).
There was no evidence of publication bias for 6MWT (p =
0.10), VO2peak (p = 0.66), Kt/V (p = 0.36), PCS (p = 0.63),
and MCS (p = 0.11) by Egger test and the NMA funnel
plot (as shown in online suppl. Fig. 6–10).
Exploration of Inconsistency
The results from the global inconsistency test were not
significant (χ2 = 7.13, p = 0.99 for 6MWT; χ2 = 4.79, p = 0.57
for VO2peak; χ2 = 6.74, p = 0.82 for Kt/V; χ2 = 13.56, p = 0.26
for PCS; χ2 = 8.30, p = 0.69 for MCS). The local incon-
sistency test using the side-splitting method showed that all
p values were larger than 0.05, indicating that the direct and
indirect comparisons between the two interventions were
consistent via the network and that NMA could be per-
formed for all outcomes by consistency models.
Risk of Bias across Studies
The risk of bias assessment for included studies was
presented in online supplementary Table S14. The overall
rates indicated that most of the studies have some con-
cerns regarding the risk of bias, 76% for 6MWT, 64% for
VO2peak, 70% for Kt/V, and 92% for HRQOL.
6 Am J Nephrol
DOI: 10.1159/000532109
Discussion
Summary of Study Findings
In this NMA of exercise in MHD patients, we found
that the most effective interventions varied depending on
the outcome of interest. IAE combined with BFR was the
most effective for the 6MWT; NCE was the most effective
for VO2peak; ICE was the most effective for Kt/V; IAE was
the most effective for the PCS of HRQOL; and NCE was
the most effective for the MCS of HRQOL.
ICE could improve all the above outcomes compared
to the UC. Therefore, we first recommend this integrated
type of exercise for most MHD patients, especially those
Downloaded from http://karger.com/ajn/article-pdf/doi/10.1159/000532109/3998785/000532109.pdf by guest on 20 November 2023
who have the necessary exercise resources (e.g., equip-
ment, knowledge, skills, and accessible exercise profes-
sionals). In addition, IAE is also recommended (for those
who have limited exercise resources) because this type of
exercise could benefit most outcomes (except MCS) and
is easier to undertake than ICE. Exercise may have a
better effect on walking capacity if it is combined with
new elements, such as BFR or VR. Because the effect of
exercise interventions on mental health is uncertain,
more attention needs to be paid to interventions that
could improve MHD patients’ mental well-being.
Interpretation
Out of the fifteen exercise modalities analyzed in this
study, nine showed improvements in the 6MWT for
patients undergoing MHD. The improvement ranged
from 22.91 m (for IRE) to 97.35 m (for IAE combined
with BFR) compared to the standard care for MHD
patients. Given that the minimal clinically important
difference for the 6MWT in similar patients is between
14.0 and 30.5 m [37, 38], we estimated the effect size to be
moderate to large, with a moderate level of confidence in
the evidence. The findings partially align with a published
Cochrane meta-analysis [39], which indicated that the
pooled effect of all exercise types on the 6MWT was an
improvement of 49.91 m for the same population.
However, our NMA offers additional insights by ranking
different exercise types [13, 28, 39], showing that IAE
combined with BFR is likely the most effective inter-
vention for improving the 6MWT. BFR exercise has been
reported as an effective complementary intervention for
deconditioned patients, as they can benefit from it even at
low-intensity levels [7, 40]. Evidence suggests that low- to
moderate-intensity AE with BFR can improve body
composition and strength in both healthy individuals [41]
and patients with chronic kidney diseases [7]. Although
the published study showed that BFR exercises were safe
in MHD patients, such techniques are complex and
Hu/Wu/Kwok/Ho/Chau/Lok/Choi
Downloaded from http://karger.com/ajn/article-pdf/doi/10.1159/000532109/3998785/000532109.pdf by guest on 20 November 2023

2
(For legend see next page.)

7
DOI: 10.1159/000532109
d

Am J Nephrol
Exercise in Hemodialysis Patients
b
a

c
should be conducted under the supervision of trained
professionals [42, 43]. In addition, as only one study in
our NMA examined this type of exercise, we must in-
terpret the results cautiously and encourage further re-
search on MHD patients.
Four types of exercise can enhance VO2peak in patients
undergoing MHD, with improvements ranging from
2.60 mL/kg per min (IAE) to 4.35 mL/kg per min (NCE)
compared to UC. The minimal clinically important dif-
ference for the VO2peak is 1.5 mL/kg per min for patients
with chronic kidney diseases [44], and we estimated the
effect size to be large although the evidence confidence is
low. This result is partly consistent with the published
NMA, which indicated that CE is the most effective mo-
dality for enhancing VO2peak [12]. Our NMA showed that
NCE is a more effective exercise modality for improving
VO2peak than other types of exercise. This superiority may
be attributed to non-dialysis exercises potentially having a
higher exercise intensity than intradialytic exercise, leading
to greater cardiopulmonary benefits [23].
Compared to UC, IAE and ICE can improve Kt/V by
0.13 and 0.17 in MHD patients, respectively. However, the
published meta-analysis did not find improvements in Kt/V
for IAE [11, 12] or all types of exercise [12, 39]. This
discrepancy may arise from different classifications of ex-
ercise types and the larger number of studies included in our
NMA. Since Kt/V is calculated from the parameter during
the hemodialysis session [45], interventions conducted
during hemodialysis may have a better effect on improving
Kt/V compared to those conducted outside of hemodialysis.
Exercise performed during hemodialysis can alter the he-
modynamics of MHD patients, allowing more fluids to
reach the dialyzer, and subsequently improve Kt/V [8].
However, our NMA showed that IRE could not improve Kt/
V, which is in line with published studies [12, 28, 39]. The
insignificant effect of IRE may be due to the limited number
of muscle groups that can move when resistance exercise is
conducted during hemodialysis [23]. As a result, they may
not reach the “muscle morphologic threshold” necessary to
increase muscle blood flow and remove urea toxins [46].
The NMA results showed that IAE and ICE could
improve the PCS score of HRQOL with pooled MDs of 4.93
and 3.90, respectively. IRE, ICE, and NCE can enhance the
Fig. 2. Network plots of studies examining the efficacy of exercise in
MHD patients: a 6-min walking test; b peak oxygen uptake; c dialysis
adequacy; d physical component summary of HRQOL; e mental
component summary of HRQOL. IAE, intradialytic aerobic exercise;
IRE, intradialytic resistance exercise; ICE, intradialytic combined
aerobic and resistance exercise; NAE, non-intradialytic aerobic ex-
ercise; NRE, non-intradialytic resistance exercise; NCE, non-
8 Am J Nephrol
DOI: 10.1159/000532109
MCS score of HRQOL with pooled MDs of 3.65, 2.92, and
6.36 in MHD patients, respectively. Given that the minimal
clinically important difference for the SF-36 scales is be-
tween three and five points [47, 48], we consider the effect
size for PCS to be small (with moderate confidence in the
evidence) and the effect for MCS to be small to moderate
(with low confidence in the evidence). These results are
partially consistent with the published pairwise meta-
analysis [18], which indicated that IAE, IRE, and ICE
could improve PCS, while only IRE could improve MCS.
We have greater confidence that IAE and ICE can enhance
PCS, as supported by this NMA and similar published
studies [11, 18, 28, 39, 49, 50]. Although NCE ranks first in
Downloaded from http://karger.com/ajn/article-pdf/doi/10.1159/000532109/3998785/000532109.pdf by guest on 20 November 2023
improving MCS, we should interpret these results cau-
tiously due to the inconsistency of effects between the
pairwise meta-analysis and NMA, as well as the limited
number of NCE studies included in the MCS analysis.
Therefore, more rigorous evidence is needed to determine
the improvement of MCS for MHD patients [5].
In this study, IAE is the most commonly reported
exercise type, followed by ICE and IRE. This is consistent
with a published study that indicated intradialytic exercise
as the most frequently reported type of exercise [23]. The
proposed benefits of intradialytic exercise include time
efficiency, ease of monitoring, low patient burden, and
safety (as it is monitored by dialysis staff) [23]. Considering
the barriers to exercise for MHD patients, such as low
physical function, limited time, and limited exercise skills
and resources, intradialytic exercise is more suitable for
this population [23, 51]. IAE, which primarily involves
pedaling a cycle ergometer during dialysis, is easier to
perform than RE (i.e., several sets of resistance movements
using different devices and workloads, requiring more
exercise skills) [23]. Based on the results of this NMA, we
recommend ICE and IAE for MHD patients who have
access to exercise resources, as these are more beneficial
and easier to perform. These two types of exercises pos-
itively impact physical function (e.g., walking capacity,
cardiorespiratory fitness, and PCS) and dialysis adequacy.
Additionally, further research exploring new elements that
could be combined with exercise, such as BFR and VR, is
warranted, as these elements may prove to be more ef-
fective than exercise alone [23, 39].
intradialytic combined aerobic and resistance exercise; IIMT, intra-
dialytic inspiratory muscle training; NIMT, non-intradialytic inspi-
ratory muscle training; CIMT, combined inspiratory muscle training
during hemodialysis and non-hemodialysis day; INES, intradialytic
neuromuscular electrical stimulation; BE, balance exercise; FT,
functional training; BFR, blood flow restriction; VR, virtual reality;
UC, usual care; SE, sham exercise.
Hu/Wu/Kwok/Ho/Chau/Lok/Choi
Table 2. Network meta-analysis results

Intervention Comparison to UC, p value Probability of being best, % SUCRA, % Studies,* n Certainty
pooled MD (95% CI)

Six-minute walking test

SE −4.20 (−33.90, 25.50) 0.781 0 10.9 0 Very low
IAE 51.14 (28.21, 74.08) <0.001 0.2 63.7 9 Low
IRE 22.91 (1.63, 44.20) 0.035 0 33.6 5 Low
ICE 53.71 (30.08, 77.35) <0.001 0.4 66.4 6 Low
NAE 44.43 (21.45, 67.41) <0.001 0.2 56.0 5 Low
NCE 45.93 (12.03, 79.83) 0.008 0.2 56.9 2 Low
INES 25.27 (−17.11, 67.65) 0.243 0.1 37.1 3 Low
IIMT 77.27 (38.14, 116.40) <0.001 14.0 84.0 2 Very low
NIMT 11.77 (−34.94, 58.48) 0.621 0 26.0 1 Very low
CIMT −4.70 (−99.16, 89.76) 0.922 1.1 21.7 1 Low
IAE + BFR 97.35 (11.89, 182.81) 0.026 47.4 86.2 1 Low
IAE + NRE 28.49 (−37.56, 94.55) 0.398 1.3 41.8 0 Very low

Downloaded from http://karger.com/ajn/article-pdf/doi/10.1159/000532109/3998785/000532109.pdf by guest on 20 November 2023

IRE + VR 77.98 (5.85, 150.12) 0.034 23.9 78.8 1 Low
NCE + balance training 66.12 (7.88, 124.35) 0.026 11.1 73.9 0 Low
Peak oxygen uptake
IAE 2.60 (0.62, 4.57) 0.010 1.6 43.6 7 Very low
ICE 3.86 (2.24, 5.49) <0.001 12.2 68.1 7 Low
NAE 4.31 (1.62, 7.00) 0.002 32.4 75.1 3 Very low
NCE 4.35 (2.25, 6.44) <0.001 29.7 77.3 4 Low
INES 1.58 (−3.38, 6.54) 0.532 8.3 33.4 1 Very low
IAE + NRE 2.46 (−2.80, 7.72) 0.360 15.9 45.3 1 Very low
Dialysis adequacy
SE −0.07 (−0.25, 0.10) 0.410 0.1 20.1 0 Low
IAE 0.13 (0.07, 0.19) <0.001 9.2 79.2 14 Low
IRE 0.07 (−0.02, 0.15) 0.116 1.1 59.4 8 Low
ICE 0.17 (0.06, 0.28) 0.002 32.1 88.0 3 Low
NRE −0.13 (−0.32, 0.05) 0.155 0.1 9.8 2 Very low
NCE 0.14 (−0.10, 0.38) 0.248 30.7 74.6 0 Low
IIMT 0.04 (−0.20, 0.28) 0.719 10.5 50.7 1 Very low
INES −0.03 (−0.19, 0.14) 0.746 0.6 31.3 2 Very low
IAE + NRE 0.02 (−0.14, 0.18) 0.840 2.0 43.0 2 Very low
IAE + FT 0.07 (−0.16, 0.31) 0.549 13.6 57.8 0 Very low
Physical component summary of HRQOL
SE 1.06 (−4.00, 6.12) 0.682 1.3 38.3 0 Very low
IAE 4.93 (2.31, 7.54) <0.001 32.5 85.4 6 Moderate
IRE 3.06 (−0.43, 6.55) 0.086 6.7 61.7 3 Low
ICE 3.90 (1.79, 6.02) <0.001 9.1 73.0 7 Very low
NAE 2.58 (−3.64, 8.79) 0.416 14.4 54.8 1 Low
NCE 1.62 (−3.66, 6.90) 0.547 6.1 45.4 0 Very low
IIMT 1.79 (−5.34, 8.92) 0.623 13.3 48.6 0 Very low
NIMT −5.44 (−10.83, −0.05) 0.048 0 2.1 1 Low
INES 3.54 (−0.80, 7.88) 0.110 16.7 66.1 2 Low
Mental component summary of HRQOL
SE 4.78 (−0.42, 9.98) 0.071 4.4 62.5 0 Low
IAE 0.33 (−2.51, 3.16) 0.820 0 15.9 6 Moderate
IRE 3.65 (0.07, 7.24) 0.046 0.7 52.0 3 Moderate
ICE 2.92 (0.12, 5.72) 0.041 0 44.2 6 Moderate
NAE 8.19 (−5.98, 22.37) 0.257 39.8 72.1 1 Very low
NCE 6.36 (0.45, 12.27) 0.035 16.0 74.5 0 Moderate
IIMT 3.97 (−17.67, 25.62) 0.719 27.8 50.5 0 Very low
NIMT 5.31 (−0.52, 11.14) 0.074 10.1 65.5 1 Low
INES 3.51 (−0.22, 7.24) 0.065 1.3 51.1 2 Moderate

Numbers in bold represent statistically significant results. MD, mean difference; 95% CI, 95% confidence interval; AE, aerobic exercise; RE, resistance
exercise; CE, combined aerobic and resistance exercise; IIMT, intradialytic inspiratory muscle training; CIMT, combined inspiratory muscle training during
hemodialysis and non-hemodialysis day; INES, intradialytic neuromuscular electrical stimulation; SUCRA, surface under the cumulative ranking; FT,
functional training; BFR, blood flow restriction; VR, virtual reality; UC, usual care; SE, sham exercise; NIMT, non-intradialytic inspiratory muscle training; IAE,
intradialytic aerobic exercise; IRE, intradialytic resistance exercise; ICE, intradialytic combined aerobic and resistance exercise; NAE, non-intradialytic aerobic
exercise; NRE, non-intradialytic resistance exercise; NCE, non-intradialytic combined aerobic and resistance exercise; HRQOL, health-related quality of life.
*Number of direct comparison studies.

Exercise in Hemodialysis Patients Am J Nephrol 9

DOI: 10.1159/000532109
Table 3. Summary of confidence in the ranking of treatments for outcomes (GRADE approach)

Outcomes Study limitations Indirectness Inconsistency Imprecision Publication Confidence

bias

Six-minute walking test Some concerns* No concerns No concerns No concerns No concerns Moderate
Peak oxygen uptake Some concerns* No concerns Some concernsa No concerns No concerns Low
Dialysis adequacy Some concerns* No concerns Some concernsa No concerns No concerns Low
Physical component summary Some concerns* No concerns No concerns No concerns No concerns Moderate
of HRQOL
Mental component summary of Some concerns* No concerns No concerns Some No concerns Low
HRQOL concernsb

GRADE, Grading of Recommendations Assessment, Development and Evaluation; HRQOL, health-related quality of life. *Evidence came
from >85% some concerns or high risk of bias studies (as shown in supplement Table S14). aHigh heterogeneity. bSome concerns of
imprecision.

Downloaded from http://karger.com/ajn/article-pdf/doi/10.1159/000532109/3998785/000532109.pdf by guest on 20 November 2023

This NMA has several strengths. Firstly, it focuses on into the impact of exercise on this population. Tailoring
the outcomes that are most relevant to MHD patients, exercise programs to individual patients’ conditions and
including physical fitness, clinical indicators, and available resources is also essential.
HRQOL. Secondly, the review employs a systematic
search strategy and rigorous analysis methodology.
Lastly, by including studies published in both English Statement of Ethics
and Chinese, the review captures a broader range of
research conducted on a larger population. An ethics statement is not applicable because this study is based
exclusively on published literature.
Limitations
Despite its strengths, there are some limitations that
cannot be overlooked. The methodology of the included Conflict of Interest Statement
studies was generally rated as moderate to high risk. Some
exercise types that ranked high in effect comparisons The authors declare that they have no conflicts of interest.
were based on only one or two studies, which could result
in less stable conclusions. Finally, this study focused
solely on the effects of different types of exercises, while Funding Sources
variations in frequency, duration, and intensity across the
included studies may have influenced the results. This study did not receive any funding support.

Conclusions
In comparison to other forms of exercise, ICE may be the
most suitable option, as it significantly improves multiple
outcomes. MHD patients should be encouraged to engage
in this type of exercise if they have access to the necessary
resources. IAE is also recommended, as it has a notable
impact on most outcomes (except MCS) and is easier to
undertake than CE. Further research is warranted to explore
the effects of combined exercise with novel elements, such
as BFR and VR, as these may enhance the benefits beyond
traditional exercise alone. Additionally, studies investigating
the effects of varying exercise duration, intensity, and fre-
quency are needed to provide more comprehensive insights
Author Contributions
Huagang Hu and Chanchan Wu: conceptualization, method-
ology, software, formal analysis, writing-original draft,
writing – review and editing, and project administration. Jojo Yan
Yan Kwok, Mu-Hsing Ho, and Kris Yuet Wan Lok: methodology,
and writing – review and editing. Pui Hing Chau: methodology,
validation, data curation and writing – review and editing. Ed-
mond Pui Hang Choi: conceptualization, methodology, data cu-
ration, writing – review and editing, and supervision.
Data Availability Statement
All data generated or analyzed during this study are included in
this article and in its supplementary materials. Further inquiries
can be directed to the corresponding author.

10 Am J Nephrol Hu/Wu/Kwok/Ho/Chau/Lok/Choi
DOI: 10.1159/000532109
 References
1 Liyanage T, Ninomiya T, Jha V, Neal B, Patrice
HM, Okpechi I, et al. Worldwide access to
treatment for end-stage kidney disease: a sys-
tematic review. Lancet. 2015;385(9981):1975–82.
2 Eckert K, Motemaden L, Alves M. Effect of
hemodialysis compared with conservative
management on quality of life in older adults
with end-stage renal disease: systematic re-
view. J Hosp Palliat Nurs. 2018;20(3):279–85.
3 Evangelidis N, Tong A, Manns B, Hemmel-
garn B, Wheeler DC, Tugwell P, et al. De-
veloping a set of core outcomes for trials in
hemodialysis: an international Delphi survey.
Am J Kidney Dis. 2017;70(4):464–75.
4 Jegatheesan DK, Modderman R, Krishnas-
amy R, Tong A, Coombes JS, Viecelli AK,
et al. A systematic review of scope and
consistency of outcome measures for physical
fitness in chronic kidney disease trials. Kid-
ney Int Rep. 2021;6(5):1280–8.
5 Mapes DL, Lopes AA, Satayathum S, Mccul-
lough KP, Goodkin DA, Locatelli F, et al.
Health-related quality of life as a predictor of
mortality and hospitalization: the Dialysis
Outcomes and Practice Patterns Study
(DOPPS). Kidney Int. 2003;64(1):339–49.
6 Ashby D, Borman N, Burton J, Corbett R,
Davenport A, Farrington K, et al. Renal
association clinical practice guideline on
haemodialysis. BMC Nephrol. 2019;
20(1):379.
7 Wilkinson TJ, McAdams-DeMarco M, Ben-
nett PN, Wilund K; Global Renal Exercise
Network. Advances in exercise therapy in
predialysis chronic kidney disease, hemodi-
alysis, peritoneal dialysis, and kidney trans-
plantation. Curr Opin Nephrol Hypertens.
2020;29(5):471–9.
8 Ferreira GD, Bohlke M, Correa CM, Dias EC,
Orcy RB. Does intradialytic exercise improve
removal of solutes by hemodialysis? A sys-
tematic review and meta-analysis. Arch Phys
Med Rehabil. 2019;100(12):2371–80.
9 Kirkman DL, Scott M, Kidd J, Macdonald JH.
The effects of intradialytic exercise on he-
modialysis adequacy: a systematic review.
Semin Dial. 2019;32(4):368–78.
10 Pu J, Jiang Z, Wu WH, Li L, Zhang LL, Li Y,
et al. Efficacy and safety of intradialytic ex-
ercise in haemodialysis patients: a systematic
review and meta-analysis. BMJ Open. 2019;
9(1):e020633.
11 Salhab N, Karavetian M, Kooman J, Fiacca-
dori E, El Khoury CF. Effects of intradialytic
aerobic exercise on hemodialysis patients: a
systematic review and meta-analysis.
J Nephrol. 2019;32(4):549–66.
12 Scapini KB, Bohlke M, Moraes OA, Ro-
drigues CG, Inacio JFS, Sbruzzi G, et al.
Combined training is the most effective
training modality to improve aerobic capacity
and blood pressure control in people re-
quiring haemodialysis for end-stage renal
Exercise in Hemodialysis Patients
disease: systematic review and network meta-
analysis. J Physiother. 2019;65(1):4–15.
13 Ferrari F, Helal L, Dipp T, Soares D, Soldatelli
Â, Mills AL, et al. Intradialytic training in
patients with end-stage renal disease: a sys-
tematic review and meta-analysis of ran-
domized clinical trials assessing the effects of
five different training interventions.
J Nephrol. 2020;33(2):251–66.
14 Bundchen DC, Sousa H, Afreixo V, Frontini
R, Ribeiro O, Figueiredo D, et al. Intradialytic
exercise in end-stage renal disease: an um-
brella review of systematic reviews and/or
meta-analytical studies. Clin Rehabil. 2021;
35(6):812–28.
15 Clyne N, Anding-Rost K. Exercise training in
chronic kidney disease-effects, expectations
and adherence. Clin Kidney J. 2021;14(Suppl
2):ii3–ii14.
16 Deligiannis A, D’Alessandro C, Cupisti A.
Exercise training in dialysis patients: impact
on cardiovascular and skeletal muscle health.
Clin Kidney J. 2021;14(Suppl 2):ii25–ii33.
17 Zhang F, Zhou WQ, Sun QZ, Zhai YY, Zhang
Y, Su H, et al. Effects of intradialytic resis-
tance exercises on physical performance,
nutrient intake and quality of life among
haemodialysis people: a systematic review
and meta-analysis. Nurs Open. 2021;8(2):
529–38.
18 Hu H, Liu X, Chau PH, Choi EPH. Effects of
intradialytic exercise on health-related qual-
ity of life in patients undergoing maintenance
haemodialysis: a systematic review and meta-
analysis. Qual Life Res. 2022;31(7):1915–32.
19 Dias EC, Orcy R, Antunes MF, Kohn R,
Rombaldi AJ, Ribeiro L, et al. Intradialytic
exercise with blood flow restriction: some-
thing to add to hemodialysis adequacy?
Findings from a crossover study. Hemodial
Int. 2020;24(1):71–8.
20 Hutton B, Salanti G, Caldwell DM, Chaimani
A, Schmid CH, Cameron C, et al. The
PRISMA extension statement for reporting of
systematic reviews incorporating network
meta-analyses of health care interventions:
checklist and explanations. Ann Intern Med.
2015;162(11):777–84.
21 Song Y, Chen L, Wang M, He Q, Xue J, Jiang
H. The optimal exercise modality and in-
tensity for hemodialysis patients incorpo-
rating Bayesian network meta-analysis and
systematic review. Front Physiol. 2022;13:
945465.
22 Zang W, Fang M, He H, Mu L, Zheng X, Shu
H, et al. Comparative efficacy of exercise
modalities for cardiopulmonary function in
hemodialysis patients: a systematic review
and network meta-analysis. Front Public
Health. 2022;10:1040704.
23 Fang HY, Burrows BT, King AC, Wilund KR.
A comparison of intradialytic versus out-of-
clinic exercise training programs for hemo-
Am J Nephrol
DOI: 10.1159/000532109
dialysis patients. Blood Purif. 2020;49(1–2):
151–7.
24 Higgins JPT, Thomas J, Chandler J, Cump-
ston M, Li T, Page MJ, et al. Cochrane
handbook for systematic reviews of inter-
ventions. 2nd ed. Hoboken (NJ): Wiley-
Blackwell; 2019.
25 Heiwe S, Jacobson SH. Exercise training for
adults with chronic kidney disease. Co-
chrane Database Syst Rev. 2011;2011(10):
CD003236.
26 Gomes Neto M, de Lacerda FFR, Lopes AA,
Martinez BP, Saquetto MB. Intradialytic ex-
ercise training modalities on physical func-
tioning and health-related quality of life in
Downloaded from http://karger.com/ajn/article-pdf/doi/10.1159/000532109/3998785/000532109.pdf by guest on 20 November 2023
patients undergoing maintenance hemodial-
ysis: systematic review and meta-analysis.
Clin Rehabil. 2018;32(9):1189–202.
27 Young HML, March DS, Graham-Brown
MPM, Jones AW, Curtis F, Grantham CS,
et al. Effects of intradialytic cycling exercise
on exercise capacity, quality of life, physical
function and cardiovascular measures in
adult haemodialysis patients: a systematic
review and meta-analysis. Nephrol Dial
Transplant. 2018;33(8):1436–45.
28 Huang M, Lv AL, Wang J, Xu N, Ma GR, Zhai
ZH, et al. Exercise training and outcomes in
hemodialysis patients: systematic review and
meta-analysis. Am J Nephrol. 2019;50(4):
240–54.
29 Ware JE. SF-36 health survey update. Spine.
2000;25(24):3130–9.
30 Sterne JAC, Savović J, Page MJ, Elbers RG,
Blencowe NS, Boutron I, et al. RoB 2: a re-
vised tool for assessing risk of bias in rand-
omised trials. BMJ. 2019;366:l4898.
31 Salanti G, Del Giovane C, Chaimani A,
Caldwell DM, Higgins JP. Evaluating the
quality of evidence from a network meta-
analysis. PLoS One. 2014;9(7):e99682.
32 Nikolakopoulou A, Higgins JPT, Papakon-
stantinou T, Chaimani A, Del Giovane C,
Egger M, et al. CINeMA: an approach for
assessing confidence in the results of a net-
work meta-analysis. PLoS Med. 2020;17(4):
e1003082.
33 Borenstein M, Hedges LV, Higgins JP, Roth-
stein HR. A basic introduction to fixed-effect
and random-effects models for meta-analysis.
Res Synth Methods. 2010;1(2):97–111.
34 Higgins JP, Thompson SG. Quantifying
heterogeneity in a meta-analysis. Stat Med.
2002;21(11):1539–58.
35 Shim S, Yoon BH, Shin IS, Bae JM. Network
meta-analysis: application and practice us-
ing Stata. Epidemiol Health. 2017;39:
e2017047.
36 Mbuagbaw L, Rochwerg B, Jaeschke R, Heels-
Andsell D, Alhazzani W, Thabane L, et al.
Approaches to interpreting and choosing the
best treatments in network meta-analyses.
Syst Rev. 2017;6(1):79.
11
37 Segura-Ortí E, Martínez-Olmos FJ. Test-
retest reliability and minimal detectable
change scores for sit-to-stand-to-sit tests, the
six-minute walk test, the one-leg heel-rise
test, and handgrip strength in people un-
dergoing hemodialysis. Phys Ther. 2011;
91(8):1244–52.
38 Bohannon RW, Crouch R. Minimal clinically
important difference for change in 6-minute
walk test distance of adults with pathology: a
systematic review. J Eval Clin Pract. 2017;
23(2):377–81.
39 Bernier-Jean A, Beruni NA, Bondonno NP,
Williams G, Teixeira-Pinto A, Craig JC, et al.
Exercise training for adults undergoing
maintenance dialysis. Cochrane Database
Syst Rev. 2022;1:CD014653.
40 Kirkman DL, Bohmke N, Carbone S, Garten
RS, Rodriguez-Miguelez P, Franco RL, et al.
Exercise intolerance in kidney diseases:
physiological contributors and therapeutic
strategies. Am J Physiol Renal Physiol. 2021;
320(2):F161–73.
41 Pope ZK, Willardson JM, Schoenfeld BJ.
Exercise and blood flow restriction. J Strength
Cond Res. 2013;27(10):2914–26.
12 Am J Nephrol
DOI: 10.1159/000532109
42 Rolnick N, Kimbrell K, Cerqueira MS,
Weatherford B, Brandner C. Perceived bar-
riers to blood flow restriction training. Front
Rehabil Sci. 2021;2(2):1–8.
43 Rolnick N, de Sousa Neto IV, da Fonseca EF,
Neves RVP, Rosa TDS, Nascimento DDC.
Potential implications of blood flow restric-
tion exercise on patients with chronic kidney
disease: a brief review. J Exerc Rehabil. 2022;
18(2):81–95.
44 Wilkinson TJ, Watson EL, Xenophontos S,
Gould DW, Smith AC. The “Minimum Clini-
cally Important Difference” in frequently re-
ported objective physical function tests after a
12-Week renal rehabilitation exercise inter-
vention in nondialysis chronic kidney disease.
Am J Phys Med Rehabil. 2019;98(6):431–7.
45 National Kidney Foundation. KDOQI clini-
cal practice guideline for hemodialysis ade-
quacy: 2015 update. Am J Kidney Dis. 2015;
66(5):884–930.
46 Pellizzaro CO, Thomé FS, Veronese FV. Ef-
fect of peripheral and respiratory muscle
training on the functional capacity of he-
modialysis patients. Ren Fail. 2013;35(2):
189–97.
47 Stewart AL, Greenfield S, Hays RD, Wells K,
Rogers WH, Berry SD. Functional status and
well-being of patients with chronic condi-
tions. Results from the Medical Outcomes
Study. JAMA. 1989;262(7):907–13.
48 Strand V, Boers M, Idzerda L, Kirwan JR,
Kvien TK, Tugwell PS, et al. It’s good to feel
better but it’s better to feel good and even
better to feel good as soon as possible for as
long as possible. Response criteria and the
importance of change at OMERACT 10.
J Rheumatol. 2011;38(8):1720–7.
49 Sheng KX, Zhang P, Chen LL, Cheng J, Wu CC,
Chen JH. Intradialytic exercise in hemodialysis
patients: a systematic review and meta-analysis.
Am J Nephrol. 2014;40(5):478–90.
50 Chung YC, Yeh ML, Liu YM. Effects of intra-
Downloaded from http://karger.com/ajn/article-pdf/doi/10.1159/000532109/3998785/000532109.pdf by guest on 20 November 2023
dialytic exercise on the physical function, de-
pression and quality of life for haemodialysis
patients: a systematic review and meta-analysis
of randomised controlled trials. J Clin Nurs.
2017;26(13–14):1801–13.
51 Li T, Lv A, Xu N, Huang M, Su Y, Zhang B, et al.
Barriers and facilitators to exercise in haemo-
dialysis patients: a systematic review of quali-
tative studies. J Adv Nurs. 2021;77(12):4679–92.
Hu/Wu/Kwok/Ho/Chau/Lok/Choi